Pediatric Anesthesiology Milestones 2.0: An Update, Rationale, and Plan Forward.

Formal training in the subspecialty of pediatric anesthesiology began >60 years ago. Over the years, the duration and clinical work has varied, but what has stayed constant is a mission to develop clinically competent and professionally responsible pediatric anesthesiologists. Since accreditation in 1997, there has been additional guidance by the Accreditation Council on Graduate Medical Education (ACGME) and greater accountability to the public that we, indeed, are producing competent and professional pediatric anesthesiologists. This has been influenced by the slow evolution from time-based educational curriculum to a competency-based paradigm. As with all ACGME-accredited specialties, education leaders in pediatric anesthesiology first convened in 2014 to design specialty-specific developmental trajectories within the framework of the 6 core competencies, known as milestones, on which fellows were to be tracked during the 1-year fellowship. With 5 years of implementation, and substantial data and feedback, it has become clear that an iterative improvement was necessary to mirror the evolution of the profession. It was evident that the community required brevity and clarity in the next version of the milestones and required additional resources for assessment and faculty development. We describe here the methodology and considerations of our working group, guided by ACGME, in the rewriting of the milestones. We also provide suggestions for implementation and collaboration to support the education and assessment of pediatric anesthesiology fellows across the country.

Do certain phrases in letters of recommendation predict success in fellowship performance?

BACKGROUND: Letters of recommendation (LORs) are a valued, yet imperfect tool. Program directors (PDs) score phrases such as give my highest recommendation and top 5 to 10% of students as positive. Although positive phrases are valued by PDs, there is no evidence that these phrases predict performance. We attempt to identify whether 12 specific phrases found in letters of recommendation predict future performance of fellows. METHODS: LORs were evaluated for 12 select phrases and statements. Alpha Omega Alpha (AOA) status, Step 2 Clinical Knowledge (CK) score, and whether the letter writer was personally known to our admission's committee were also categorized. Logistic regressions were performed to evaluate the relationship of the independent variables with fellow performance. RESULTS: Using multivariate logistic regression, one of the best residents (OR = 4.02, 95% CI (1.0, 15.9), p < 0.05), exceeds expectations (OR = 4.74, 95% CI (1.4, 16.3), p = 0.01), and give my highest recommendation (OR = 3.87, 95% CI (1.3, 11.7), p = 0.02) predicted positive performance. Highly recommend (OR = 0.31, 95% CI (0.1, 1.0), p < 0.05) and top 5 to 10% (OR = 0.05, 95% CI (0.0, 0.6), p = 0.02) predicted negative performance. The remaining phrases did not correlate to fellowship performance. CONCLUSION: The current LOR evaluation process may place undo importance on phrases that have limited bearing on a candidate's success in training. Training both letter readers and writers to avoid using coded language or avoid assigning improper importance to select phrases may help improve the candidate selection process.

The Anesthesiology Milestones 2.0: An Improved Competency-Based Assessment for Residency Training.

The evolution of medical education, from a time-based to a competency-based platform, began nearly 30 years ago and continues to slowly take shape. The development of valid and reproducible assessment tools is the first step. Medical educators across specialties acknowledge the challenges and remain motivated to develop a relevant, generalizable, and measurable system. The Accreditation Council for Graduate Medical Education (ACGME) remains committed to its responsibility to the public by assuring that the process and outcome of graduate medical education in the nation's residency programs produce competent, safe, and compassionate doctors. The Milestones Project is the ACGME's current strategy in the evolution to a competency-based system, which allows each specialty to develop its own set of subcompetencies and 5-level progression, or milestones, along a continuum of novice to expert. The education community has now had nearly 5 years of experience with these rubrics. While not perfect, Milestones 1.0 provided important foundational information and insights. The first iteration of the Anesthesiology Milestones highlighted some mismatch between subcompetencies and current and future clinical practices. They have also highlighted challenges with assessment and evaluation of learners, and the need for faculty development tools. Committed to an iterative process, the ACGME assembled representatives from stakeholder groups within the Anesthesiology community to develop the second generation of Milestones. This special article describes the foundational data from Milestones 1.0 that was useful in the development process of Milestones 2.0, the rationale behind the important changes, and the additional tools made available with this iteration.